Public Health and the Common Good
In the frenzied debates about health care reform in the United States, we have unfortunately dumbed ourselves down to debate the pros and cons of making a dysfunctional system bigger. Indeed, more is spent in the U.S. than most other industrialized nations, only to find that Americans are generally sicker than other industrialized, wealthy nations. Many of our debates frequently involve irreconcilable assumptions about what health care people ought to have unrestrained access to or how that health care can be delivered. In order to have a meaningful conversation—especially within conservative evangelicalism—in regards to health care policy, we must examine both the definition and value of health and consider in particular the value of public health to the common good.
Wendell Berry helpfully observes:
The word "health," in fact, comes from the same Indo-European root as "heal," "whole," and "holy." To be healthy is literally to be whole; to heal is to make whole. I don't think mortal healers should be credited with the power to make holy. But I have no doubt that such healers are properly obliged to acknowledge and respect the holiness embodied in all creatures, or that our healing involves the preservation in us of the spirit and the breath of God.
Thus, just as "peace" is not merely the absence of war, so "health" is not merely the treatment of disease.
Public health is an expansive concept encompassing both prevention and treatment of illness at the community or national level. Leaving aside the question of whether access to health care is a right (others have weighed in on this), it is enough to say that working for public health is enough of a feature of the common good that Christians should seek to implement policies that promote health, not only in individuals, but also in communities. Looking at specific populations—whether it is the entire population of a nation, the people in a particular region, a high-risk group, or everyone of a certain age—helps health authorities, practitioners, and community groups to maximize the benefits of any particular intervention.
Prevention can both involve active interventions (such as paying for immunizations and exercise programs) as well as passive policies (such as environmental regulations). Embracing the idea that the health of other humans created in the imago Dei requires an active cultivation of the environment in which we live is a crucial first step to pursuing the common good inherent in public health. It is well-established, for example, that the measures taken in recent decades against smoking have seen great dividends in smoking cessation; while the consequence of many of these interventions have resulted in individuals changing their behaviour, the environment cultivated by policy has shaped these behaviours. Agricultural subsidies are a less straightforward example, but it is hard to argue that subsidizing the production of cheaply made carbohydrates has not helped to drive down the prices of foods that in turn are linked to obesity and diabetes.
Other policies regarding active interventions to prevent disease are also straightforward: if the state pays for a significant number of childhood immunizations and then mandates that every child whose parents do not have a conscientious objection must be immunized, then immunization rates will increase. Others are less obvious; for example, the evidence clearly demonstrates that getting an "annual physical" does not improve one's quality or quantity of life, yet getting certain tests that are usually ordered at these physicals (like mammograms and blood pressure checks) improve both dramatically. Furthermore, regions with an imbalance of doctors favouring specialists over primary care providers will fare worse than regions that are more heavily populated with primary care clinicians (which may reflect both the cost and outcomes discrepancies seen between the U.S. and other countries, as other countries pay their specialists far less than we Americans do).
Treatment and management of acute and chronic illnesses is usually a far more complex issue for public health. While promoting a culture that values certain habits of eating and exercising is beneficial for both preventing and treating a great number of diseases, the interactions between sick people and the health care system rely on far more difficult metrics. One very simple example of public health and acute surgical illness was explored recently by a missionary surgeon who discovered that children were coming to his hospital after choking on a cheap plastic toy with a loose piece. However, untangling cause and effect and then proposing a solution is rarely that simple. The classic illustration of public health strategy is that of a man who pulls a drowning stranger from a river, then sees someone else drowning as soon as he has pulled the stranger to safety. He does this several times, rescuing several drowning souls before he realizes that he should go upriver and find out why people are falling in. (See here for more variations on the story that add layers of nuance.)
It is important to recognize that all Americans do have access to emergency services, while millions do not have access to treatment for chronic illnesses. The Affordable Care Act sought to remedy this disparity through the individual mandate and Medicaid expansion in a move that has still left many millions uninsured. Health insurance remains inaccessibly expensive to many people in the U.S., increasing the likelihood that chronic illnesses will not be treated and more people will suffer early death or disability. Thus, any approach to health care reform with public health in mind must find a way to ensure universal access. It is equally important to recognize that this doesn't necessarily entail embracing a single payer system, nor does health insurance automatically equal access to health care—especially as the U.S. system continues to struggle with an inadequate numbers of primary care providers, rising copays, and shrinking networks. It is unfortunate that the debate during the Affordable Care Act was not one in which the merits of a single-payer model were contrasted with that of a more free-market system; rather, the discussion centred on how the government would continue to subsidize insurance companies, pharmaceutical manufacturers, and hospital networks.
People must have access to care that not only reflects good scientific evidence that it will benefit their lives, but must also be shaped by the values of community and continuity. The interventions delivered through churches that have the most benefit in the poorest communities in America are those that involve the local community and are informed by the value systems of congregants. While the Church has done an admirable job at speaking out against the medical-ethical horrors of abortion and euthanasia, it has lagged in creating a culture that supports the most vulnerable unwed mothers or fosters good end-of-life decision-making. We have a well-developed comprehensive ethic of human life, but the fact that enormous numbers of children are still aborted and enormous sums of money are spent on potentially wasteful end-of-life care demonstrate that these ethics have not trickled down into discipleship and pastoral ministry like they ought.
Much of the Church's role in preventing illness does involve actively resisting the cultural urges that drive destructive consumption. Many young and skinny Christians like to bring up the fact that gluttony is never discussed as a sin (usually to try to throw off discussion about other sins). However, one could argue that gluttony is a less useful framework for understanding obesity because our diets often reflect the food that is more available to us just as much as they reflect deliberate choices that we make. A church body that reflects good stewardship of our physical bodies will teach and preach on how to shape our consumption patterns to glorify God's creation, but it is not enough to merely challenge individuals to eat better—we must look at our corporate habits of consumption. Many individuals make a lot of money selling people things that are harmful to their bodies; doctors and hospitals in turn make a lot of money in treating the effects of those harms. Furthermore, the medical systems of care that are reimbursed do not lend themselves easily to the sort of culture-shaping and community-driven change needed to combat the forces that profit from overconsumption. The church, then, stands as an intermediary institution helping to protect communities from both the excesses of these forces as well as prune back the need for further state management of health.
Why does this matter to those of us attempting to promulgate the common good? For one, we believers value our elders. While one can debate the theological benefits of merely "extending life," I think that we can agree that when valued members of our congregations die or become disabled at a younger age than if they had received the benefits of prevention and treatment, we weaken the church by losing some of its experienced members. This is not just about helping seventy-year-olds live to be seventy-two, but preventing a forty-five-year-old with diabetes and hypertension from dying at age fifty so he or she can live another ten or twenty years.
Furthermore, public health is often a matter of justice. The poor in the U.S. (particularly the rural poor) suffer the most from the holes in the broken healthcare system, and while charity care does a great deal of good for a great number of people, it is clearly insufficient to meet the needs of the population. The most robust Christian health care providers do not operate from a strictly charity model because the cost of care is simply too high to do so—for many of them, a large portion of their budget is sustained through Medicaid and Medicare. Charity is essential but cannot be the basis of service to the health of the poor.
One might object that the state is quite frequently the means by which public health services are rendered. While this does often represent a curtailing of particular liberties, it is important to remember that, first, there is Biblical precedent for laws that reflect public health (Exodus 21:21-28, Leviticus 14:43-53, Deuteronomy 22:8.) Secondly, if we assume that Jesus's commands to his disciples to both preach and heal (Luke 10:8) continue to rest on us, then we have to honestly assess whether or not an intervention that can heal (or prevent disease) in an entire population can best be delivered by the state. If public health is a public good—like jersey walls and police officers that both prevent harm and rectify it—then it is only right that public funds collected through taxation be used to support it. The presupposition of any public health intervention is that there is an overall benefit to the community or population that has been targeted as a whole; there are clearly some interventions that are so efficacious that it would be unjust to deny them to all citizens and some risk factors that are so harmful that it would be unjust to allow any citizen to be negligently exposed to them.
If we believe (as we should!) that the flourishing of human civilization depends on having a robust moral ecology that is shaped not only by our proclamation of God's truth but also by the law (as many Christians who oppose the legalization of same-sex marriage have argued), then recognizing the role of the state in promoting public health becomes all the more important. People who have lived most of their lives experiencing the benefit of invisible privilege are most prone to forget the fact that their good behaviours are not just the result of their own individual self-determination and moral conscience, but to a legacy of culture, tradition, and law that shaped said conscience. The state can never fulfill all the roles in shaping this moral ecology (or our physical ecology), but there are some that it should fulfill in order to equitably promote the health of all of its members. It is important, then, that the church thoughtfully embrace the logic of public health so that it can support the state in interventions that may be costly but worthwhile and prophetically challenge the state in endeavours that are contrary to the wisdom of Scripture.
Finally, public health matters to believers because our bodies matter not just as individuals, but as a community. If we have been given our bodies as a gift from God to enjoy Him, it follows that our bodies are to be shepherded through our earthly life with the utmost care. Paul teaches us that our earthly bodies are seeds that flower in the Resurrection; one might look at public health as the means by which we ensure the highest quality of the soil, water, and air that those seeds germinate in. While each individual will flower differently, the physical and spiritual environment that we live in will shape the meadow or forest that we will become. When we promote public health as a function of the common good, we bring the knowledge of how to best care for God's creation to bear on the crowning glory of that creative work.